Noise in the ICU patient room – Staff knowledge and clinical improvements

The introduction of a sound reduction bundle in the intensive care unit and its impact on sound levels and patients

BACKGROUND

ICU outcomes are continuing to improve. However, this has not been matched by similar improvements of the ICU bedspace environment, which can detrimentally impact on patient outcomes. Excessive sound and noise, especially, has been linked with adverse and potentially preventable patient outcomes and staff errors. There are many sources of sound in the ICU, with alarms from bedside equipment frequently listed as a main source. The number of alarms is increasing in parallel with the introduction of new and more sophisticated technologies to monitor and support patients. However, most alarms are not accurate or critical and are commonly ignored by staff.

OBJECTIVE

The objective of this study was to evaluate the impact of a sound reduction bundle on sound levels, number of alarms, and patients' experience and perceived quality of sleep in the ICU.

METHODS

This was a pre-post, quasi-experimental study investigating the impact of three study interventions implemented sequentially (staff education, visual warnings when sound levels exceeded the preset levels, and monitor alarm reconfigurations). Effects of staff education were evaluated using pre-education and post-education questionnaires, and the impact on patients was evaluated via self-report questionnaires. A sound-level monitor was used to evaluate changes in sound levels between interventions. Alarm audits were completed before and after alarm reconfiguration.

RESULTS

Staff knowledge improved; however, sound levels did not change across interventions. The number of monthly monitor alarms reduced from 600,452 to 115,927. No significant differences were found in patients' subjective rating of their experience and sleep.

CONCLUSION

The interventions did not lead to a sound-level reduction; however, there was a large reduction in ICU monitor alarms without any alarm-related adverse events. As the sources of sound are diverse, multidimensional interventions, including staff education, alarm management solutions, and environmental redesign, are likely to be required to achieve a relevant, lasting, and significant sound reduction.

Effectiveness of Earplugs and Eye Masks on Sleep Quality and Fatigue Among Nonventilated Patients in an Intensive Care Unit

BACKGROUND

Sleep is a basic physiological need and is imperative for healing and rejuvenation. However, the environment of the intensive care unit (ICU), including loud sounds and bright lights, can undermine patients' sleep quality.

AIM

This study was designed to determine the effectiveness of overnight use of earplugs and eye masks to improve sleep quality and potentially influence hemodynamic parameters and mitigate fatigue among nonventilated patients in an ICU.

MATERIALS AND METHODS

This experimental study was conducted among 84 nonventilated patients in an ICU. The patients were evenly divided between an intervention group (n=42) and a control group (n=42). The intervention group patients received earplugs and eye masks for three consecutive nights from 10:30 pm to 6:30 am, while the control group patients received routine care. Clinical data, responses to the Richards-Campbell sleep questionnaire, and rankings on a numerical fatigue scale were collected before (pretest) and after the intervention each night and the next morning (posttests 1, 2, and 3).

RESULTS

The results revealed a significant reduction in fatigue. At pretest, fatigue scores in the study group were 4.19±1.64. The score was significantly reduced to 3.40±1.39 at posttest 1 and then to 2.21±1.00 at posttest 3 (p<0.0001). The sleep quality for the study group showed a significant improvement from the pretest score of 43.73±8.27 to 60.35±6.85 at posttest 3 (p<0.001), whereas the control group had slightly worse sleep quality, with 40.64±8.67 at pretest and 45.63±6.95 at posttest 3.

CONCLUSIONS

Continuous patient monitoring is an essential nursing care activity in ICUs while ensuring good-quality sleep promotes healing and reduces fatigue. Sleep quality can be supported by devices such as earplugs and eye masks to limit undue disturbances in the ICU settings.

Noise exposure among staff in intensive care units and the effects of unit-based noise management: a monocentric prospective longitudinal study

BACKGROUND

Intensive care units (ICUs) are often too noisy, exceeding 70-80 dBA, which can have negative effects on staff. The corresponding recommendation of the World Health Organization (average sound pressure level below 35 dBA) is often not achieved. To date there is a lack of intervention studies examining the extent to which unit-based noise management in ICUs contributes to a reduction in noise exposure for the staff. The study therefore aims to provide answers to 1) how unit-based noise management sustainably reduces the subjective noise exposure among staff, and 2) how this intervention affects other noise-related topics.

METHODS

We performed a monocentric prospective longitudinal study with three measurement points in a German university hospital in three ICUs. We collected data from different healthcare professionals and other professional groups between October 2021 and August 2022 using an online questionnaire. Data were analyzed using descriptive and inference statistics.

RESULTS

A total of n = 179 participants took part in the surveys. The majority of participants were nurses or pediatric nurses. Most participants worked more than 75% full-time equivalent. Staff on the three ICUs reported high levels of noise exposure. No significant changes in noise exposure over time were observed. Participants were already aware of the topic and believed that a behavior change could positively influence the noise environment.

CONCLUSIONS

This study provides an initial insight into how a unit-based noise management could contribute to a reduction in the subjective noise exposure among staff in ICUs. The results of this study highlight the importance of this topic. Future studies should aim to research aspects of adherence and their facilitators or barriers, which promote the sustained implementation of noise-reducing measures by staff.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00025835; Date of registration: 12.08.2021.

Noise in cesarean deliveries: a comprehensive analysis of noise environments in the Labor and Delivery operating room and evaluation of a visual alarm noise abatement program

BACKGROUND

Cesarean delivery is the most common major surgery worldwide. Noise in healthcare settings leads to impaired communication and concentration, and stress among healthcare providers. Limited information is available about noise at cesarean delivery.

OBJECTIVE

This study aimed to achieve a comprehensive analysis of noise that occurs during cesarean deliveries. Sound level meters are used to determine baseline noise levels and to describe the frequency of acute noise generated during a cesarean delivery that will cause a human startle response. Secondarily, we aimed to evaluate the effectiveness of a visual alarm system in mitigating excessive noise.

STUDY DESIGN

We completed a preintervention/postintervention observational study of noise levels during cesarean deliveries before and after introduction of a visual alarm system for noise mitigation between February 15, 2021 and August 26, 2021. There were 156 cases included from each study period. Sound pressure levels were analyzed by overall case median decibel levels and by time epoch for relevant phases of the operation. Rapid increases in noise events capable of causing a human startle response, "startle events," were detected by retrospective analysis, with quantification for baselines and analysis of frequency by case type. Median noise levels with interquartile ranges are presented. Data are compared between epochs and case characteristics with nonparametric 2-tailed testing.

RESULTS

The median acoustic pressure for all cesarean deliveries was 61.8 (58.8-65.9) (median [interquartile range]) dBA (A-weighted decibels). The median dBA for the full case time period was significantly higher in cases with neonatal intensive care unit team presence (62.1 [60.5-63.9]), admission to the neonatal intensive care unit (62.0 [60.4-63.9]), 5-minute Apgar score <7 (62.2 [61.1-64.3]), multiple gestations (62.6 [62.0-64.2]), and intraoperative tubal sterilization (62.8 [61.5-65.1]). The use of visual alarms was associated with a statistically significant reduction of median noise level by 0.7 dBA, from 61.8 (60.6-63.5) to 61.1 (59.8-63.7) dBA (P<.001).

CONCLUSION

The noise intensities recorded during cesarean deliveries were commonly at levels that affect communication and concentration, and above the safe levels recommended by the World Health Organization. Although noise was reduced by 0.7 dBA, the reduction was not clinically significant in reaching a discernible amount (a 3-dB change) or in reducing "startle events." Isolated use of visual alarms during cesarean deliveries is unlikely to be a satisfactory noise mitigation strategy.

Mapping the impact of ICU design on patients, families and the ICU team: A scoping review

PURPOSE

Scoping review to map outcomes and describe effects of intensive care unit (ICU) design features on patients, family, and healthcare professionals (HCPs).

MATERIALS AND METHODS

Iteratively developed search strategy executed across seven databases. We included studies (January 2007 to May 2020) exploring ICU design features using any study design. We grouped studies into 12 design features and categorized outcomes into four domains.

RESULTS

Of 18,577 citations screened, 44 studies met inclusion criteria. Newly built or renovated ICUs/ICU rooms were evaluated in 27 (61%) studies; 17 (39%) evaluated existing designs/features. Most commonly evaluated design features were lighting (24, 55%), single vs multi-occupancy rooms/pods (17, 39%), and family-centered design (13, 30%). We identified 63 distinct outcomes in four domains; HCP-related (20, 45%); patient-related (20, 45%); family-related (11, 25%); and environment-related (7, 16%). Eleven (25%) studies measured patient/family-reported outcomes. In studies evaluating single occupancy rooms, three reported increased family satisfaction, two reported decreased delirium burden, while six reported negative consequences on HCP wellbeing and working.

CONCLUSION

Studies evaluating ICU design measure disparate outcomes. Few studies included patient/ family-reported outcomes; fewer measured objective environment characteristics. Single room layouts may benefit patients and family but contribute to adverse HCP-related outcomes.

The relationship between sensory stimuli and the physical environment in complex healthcare settings: A systematic literature review

OBJECTIVES

This systematic review presented the current status of literature on the outcomes resulted from sensory stimuli in critical care environments as well as the environmental interventions that can improve or impede the impact of such sensory stimuli.

METHODS

Articles found through a systematic search of PsycINFO, Web of Science, and PubMed databases, in combination with a hand search, were reviewed for eligibility by two independent coders. Reporting and quality appraisals were based on PRISMA and MMAT guidelines.

RESULTS

Out of 1118 articles found, and only 30 were eligible. Final articles were comprised of issues related to noise, lighting, and temperature. Identified sensory stimuli resulted in psychological and physiological outcomes among both patients and staff. Examples include impacts on stress, delirium, sleep disturbances, poor performance and communication. The environmental factors that influence sensory stimuli included layout, room size, artificial lighting, presence of windows and acoustical interventions.

CONCLUSION

Literature on the impact of sensory stimuli on staff is scarce compared to patients. Studies on environmental interventions are inadequate and lack structure. The physical environment can impact the patient and staff outcome resulting from noise, lighting, and temperature. When applied strategically, sensory stimuli can result in positive outcomes among patients and staff.

Betwixt and between: a surgical post-acute treatment unit (SPA) for the optimal care of elderly patients with isolated hip fractures

BACKGROUND

A performance improved project identified elderly trauma patients to have a disproportionate incidence of complications.

AIMS

The purpose of this study was to assess the efficacy of a small specialty care unit to decrease complications in patients who no longer warrant care in an intensive care unit (ICU).

METHODS

A surgical post-acute treatment unit (SPA) was developed with focused attention to cognition, nutrition, respiration, and mobilization needs of patients who no longer had physiologic need for an intensive care unit environment, but were still in need of increased attention at the bedside.

RESULTS

While ICU and hospital lengths of stay were unchanged, patients placed in the SPA experienced less complications and required less unplanned ICU re-admissions.

DISCUSSION

Geriatric patients, especially the elderly, are not simply old adults. They have unique needs as a consequence of the aging process, which can be encompassed by four pillars of intercession: cognition, nutrition, respiration, and mobilization.

CONCLUSIONS

By adapting a physical environment supported by bedside attention to address the interwoven needs of geriatric and elderly patients who no longer care in an ICU, complications and unplanned return admissions to the ICU can be decreased.

LEVEL OF EVIDENCE

III.

Psychogenic stress in hospitalized veterinary patients: Causation, implications, and therapies

OBJECTIVE

To review the sources, adverse effects, diagnosis, treatment, and prevention of psychogenic stress in hospitalized human and veterinary patients.

DATA SOURCES

Data were collected by searching PubMed for veterinary and human literature from the past 10 years.

HUMAN DATA SYNTHESIS

Psychogenic stress has been linked to immune suppression; gastrointestinal, cardiovascular, and cutaneous diseases; delayed wound healing; alterations in pain perception; and neurologic impairment. Sources of psychogenic stress include environmental alterations such as excessive noise and light, social and physical factors, sleep disruption, drugs, and underlying disease. Nonpharmacologic options for stress reduction include environmental and treatment modifications, music therapy, and early mobilization. Pharmacologic options include sedation with benzodiazepines and dexmedetomidine. Trazodone and melatonin have been examined for use in sleep promotion but are not currently recommended as standard treatments in ICU.

VETERINARY DATA SYNTHESIS

Activation of the stress response in veterinary patients is largely the same as in people, as are the affected body systems. Possible sources of stress can include social, physical, and environmental factors. No gold standard currently exists for the identification and quantification of stress. A combination of physical examination findings and the results of serum biochemistry, CBC, and biomarker testing can be used to support the diagnosis. Stress scales can be implemented to identify stressed patients and assess severity. Nonpharmacologic treatment options include low-stress handling, pheromones, environmental modifications, and sleep promotion. Pharmacologic options include trazodone, benzodiazepines, dexmedetomidine, and melatonin.

CONCLUSION

The prevalence and clinical significance of psychogenic stress in hospitalized veterinary patients is unknown. Future studies are needed to specifically examine the causative factors of psychogenic stress and the effects of various therapies on stress reduction. The recognition and reduction of psychogenic stress in veterinary patients can lead to improvements in patient care and welfare.

Sound as a supportive design intervention for improving health care experience in the clinical ecosystem: A qualitative study

PURPOSE

Most prior hospital noise research usually deals with sound in its noise facet and is based merely on sound level abatement, rather than as an informative or orientational element. This paper stimulates scientific research into the effect of sound interventions on physical and mental health care in the clinical environment.

METHODS

Data sources comprised relevant World Health Organization guidelines and the results of a literature search of ISI Web of Science, ProQuest Central, MEDLINE, PubMed, Scopus, JSTOR and Google Scholar.

RESULTS

Noise induces stress and impedes the recovery process. Pleasant natural sound intervention which includes singing birds, gentle wind and ocean waves, revealed benefits that contribute to perceived restoration of attention and stress recovery in patients and staff.

CONCLUSIONS

Clinicians should consider pleasant natural sounds perception as a low-risk non-pharmacological and unobtrusive intervention that should be implemented in their routine care for speedier recovery of patients undergoing medical procedures.

Nursing staff's experiences of working in an evidence-based designed ICU patient room-An interview study

INTRODUCTION

It has been known for centuries that environment in healthcare has an impact, but despite this, environment has been overshadowed by technological and medical progress, especially in intensive care. Evidence-based design is a concept concerning integrating knowledge from various research disciplines and its application to healing environments.

OBJECTIVE

The aim was to explore the experiences of nursing staff of working in an evidence-based designed ICU patient room.

METHOD

Interviews were carried out with eight critical care nurses and five assistant nurses and then subjected to qualitative content analysis.

FINDINGS

The experience of working in an evidence-based designed intensive care unit patient room was that the room stimulates alertness and promotes wellbeing in the nursing staff, fostering their caring activities but also that the interior design of the medical and technical equipment challenges nursing actions.

CONCLUSIONS

The room explored in this study had been rebuilt in order to create and evaluate a healing environment. This study showed that the new environment had a great impact on the caring staffs' wellbeing and their caring behaviour. At a time when turnover in nurses is high and sick leave is increasing, these findings show the importance of interior design ofintensive care units.